Washington Apple Health (Medicaid)
Outpatient Rehabilitation Billing Guide October 1, 2016
Every effort has been made to ensure this guide’s accuracy. If an actual or apparent conflict between this
document and an agency rule arises, the agency rules apply.
About this guide*
This publication takes effect October 1, 2016, and supersedes earlier billing guides to this
program.
HCA is committed to providing equal access to our services. If you need an accommodation or
require documents in another format, please call 1-800-562-3022. People who have hearing or
speech disabilities, please call 711 for relay services.
Washington Apple Health means the public health insurance programs for eligible
Washington residents. Washington Apple Health is the name used in Washington
State for Medicaid, the children's health insurance program (CHIP), and state-only
funded health care programs. Washington Apple Health is administered by the
Washington State Health Care Authority.
Services and equipment related to the programs listed below are not covered by this billing guide
and must be billed using their program-specific billing guide:
Home Health Services
Neurodevelopmental Centers
Wheelchairs, Durable Medical Equipment, and Supplies
Prosthetic/Orthotic Devices and Supplies
Outpatient Hospital Services
Physician-Related Services/Healthcare Professional Services (includes Audiology)
What has changed?
Subject Change Reason for Change
Billing and Claim
Forms
Effective October 1, 2016, all claims must be
filed electronically. See blue box
notification.
Policy change to
improve efficiency in
processing claims
*This publication is a billing instruction.
3
How can I get agency provider documents?
To access provider alerts, go to the agency’s provider alerts web page.
To access provider documents, go to the agency’s provider billing guides and fee schedules web
page.
Copyright disclosure
Current Procedural Terminology (CPT) copyright 2015 American
Medical Association (AMA). All rights reserved. CPT is a
registered trademark of the AMA.
Fee schedules, relative value units, conversion factors and/or
related components are not assigned by the AMA, are not part of
CPT, and the AMA is not recommending their use. The AMA does
not directly or indirectly practice medicine or dispense medical
services. The AMA assumes no liability for data contained or not
contained herein.
Outpatient Rehabilitation
Alert! This Table of Contents is automated. Click on a page number to go directly to the page. 4
Table of Contents
Important Changes to Apple Health Effective April 1, 2016 .....................................................6
New MCO enrollment policy – earlier enrollment ....................................................................6 How does this policy affect providers? ................................................................................7
Behavioral Health Organization (BHO) ....................................................................................7 Fully Integrated Managed Care (FIMC) ....................................................................................7 Apple Health Core Connections (AHCC)..................................................................................8
AHCC complex mental health and substance use disorder services ...................................8 Contact Information for Southwest Washington .......................................................................9
Resources Available .....................................................................................................................10
Client Eligibility ...........................................................................................................................11
How can I verify a patient’s eligibility? ..................................................................................11 Are clients enrolled in an agency-contracted managed care organization (MCO)
eligible? ..............................................................................................................................12 Are clients enrolled in Primary Care Case Management (PCCM) eligible? ...........................12
Provider Eligibility.......................................................................................................................13
Who may provide outpatient rehabilitation services? ..............................................................13
Coverage .......................................................................................................................................14
When does the agency pay for outpatient rehabilitation? ........................................................14
What outpatient rehabilitation does the agency cover for clients age 20 and younger? ..........15 Which clients receive short-term outpatient rehabilitation coverage? .....................................15 What clinical criteria must be met for the short-term outpatient rehabilitation benefit? .........15
What are the short-term outpatient rehabilitation benefit limits? ............................................16 Occupational therapy .........................................................................................................17
Physical therapy .................................................................................................................18 Speech therapy ...................................................................................................................19
Swallowing evaluations .....................................................................................................20 Using timed and untimed procedure codes ........................................................................20
What are habilitative services under this program? .................................................................20 How do I bill for habilitative services? ....................................................................................21
Coverage Table.............................................................................................................................22
Where can I find the fee schedule? ..........................................................................................29
Authorization................................................................................................................................30
What are the general guidelines for authorization? .................................................................30
EPA – What are the additional units for clients age 21 and older, and clients age 19
through 20 in MCS? ...........................................................................................................30 How can I request an LE? ........................................................................................................31
Outpatient Rehabilitation
Alert! This Table of Contents is automated. Click on a page number to go directly to the page. 5
Billing and Claim Forms .............................................................................................................32
Are referring provider NPIs required on all claims? ...............................................................32
How is the CMS-1500 claim form completed? .......................................................................32 Are modifiers required for billing? ..........................................................................................32 What are the general billing requirements? .............................................................................33 Home health agencies ..............................................................................................................33 Outpatient hospital or hospital-based clinic setting .................................................................34
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
6
Important Changes to
Apple Health
Effective April 1, 2016
These changes are important to all providers
because they may affect who will pay for services.
Providers serving any Apple Health client should always check eligibility and confirm plan
enrollment by asking to see the client’s Services Card and/or using the ProviderOne Managed
Care Benefit Information Inquiry functionality (HIPAA transaction 270). The response (HIPAA
transaction 271) will provide the current managed care organization (MCO), fee-for-service, and
Behavioral Health Organization (BHO) information. See the Southwest Washington Provider
Fact Sheet on the agency’s Early Adopter Region Resources web page.
New MCO enrollment policy – earlier enrollment
Beginning April 1, 2016, Washington Apple Health (Medicaid) implemented a new managed
care enrollment policy placing clients into an agency-contracted MCO the same month they are
determined eligible for managed care as a new or renewing client. This policy eliminates a
person being placed temporarily in fee-for-service while they are waiting to be enrolled in an
MCO or reconnected with a prior MCO.
New clients are those initially applying for benefits or those with changes in their existing
eligibility program that consequently make them eligible for Apple Health Managed
Care.
Renewing clients are those who have been enrolled with an MCO but have had a break in
enrollment and have subsequently renewed their eligibility.
Clients currently in fee-for-service or currently enrolled in an MCO are not affected by this
change. Clients in fee-for-service who have a change in the program they are eligible for may be
enrolled into Apple Health Managed Care depending on the program. In those cases, this
enrollment policy will apply.
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
7
How does this policy affect providers?
Providers must check eligibility and know when a client is enrolled and with which
MCO. For help with enrolling, clients can refer to the Washington Healthplanfinder’s Get
Help Enrolling page.
MCOs have retroactive authorization and notification policies in place. The provider must
know the MCO’s requirements and be compliant with the MCO’s new policies.
Behavioral Health Organization (BHO)
The Department of Social and Health Services (DSHS) manages the contracts for behavioral
health (mental health and substance use disorder (SUD)) services for nine of the Regional
Service Areas (RSA) in the state, excluding Clark and Skamania counties in the Southwest
Washington (SW WA) Region. BHOs will replace the Regional Support Networks (RSNs).
Inpatient mental health services continue to be provided as described in the inpatient section of
the Mental Health Billing Guide. BHOs use the Access to Care Standards (ACS) for mental
health conditions and American Society of Addiction Medicine (ASAM) criteria for SUD
conditions to determine client’s appropriateness for this level of care.
Fully Integrated Managed Care (FIMC)
Clark and Skamania Counties, also known as SW WA region, is the first region in Washington
State to implement the FIMC system. This means that physical health services, all levels of
mental health services, and drug and alcohol treatment are coordinated through one managed
care plan. Neither the RSN nor the BHO will provide behavioral health services in these
counties.
Clients must choose to enroll in either Community Health Plan of Washington (CHPW) or
Molina Healthcare of Washington (MHW). If they do not choose, they are auto-enrolled into one
of the two plans. Each plan is responsible for providing integrated services that include inpatient
and outpatient behavioral health services, including all SUD services, inpatient mental health and
all levels of outpatient mental health services, as well as providing its own provider
credentialing, prior authorization requirements and billing requirements.
Beacon Health Options provides mental health crisis services to the entire population in
Southwest Washington. This includes inpatient mental health services that fall under the
Involuntary Treatment Act for individuals who are not eligible for or enrolled in Medicaid, and
short-term substance use disorder (SUD) crisis services in the SW WA region. Within their
available funding, Beacon has the discretion to provide outpatient or voluntary inpatient mental
health services for individuals who are not eligible for Medicaid. Beacon Health Options is also
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
8
responsible for managing voluntary psychiatric inpatient hospital admissions for non-Medicaid
clients.
In the SW WA region some clients are not enrolled in CHPW or Molina for FIMC, but will
remain in Apple Health fee-for-service managed by the agency. These clients include:
Dual eligible – Medicare/Medicaid
American Indian/Alaska Native (AI/AN)
Medically needy
Clients who have met their spenddown
Noncitizen pregnant women
Individuals in Institutions for Mental Diseases (IMD)
Long-term care residents who are currently in fee-for-service
Clients who have coverage with another carrier
Since there is no BHO (RSN) in these counties, Medicaid fee-for-service clients receive complex
behavioral health services through the Behavioral Health Services Only (BHSO) program
managed by MHW and CHPW in SW WA region. These clients choose from CHPW or MHW
for behavioral health services offered with the BHSO or will be auto-enrolled into one of the two
plans. A BHSO fact sheet is available online.
Apple Health Core Connections (AHCC)
Coordinated Care of Washington (CCW) will provide all physical health care (medical)
benefits, lower-intensity outpatient mental health benefits, and care coordination for all
Washington State foster care enrollees. These clients include:
Children and youth under the age of 21 who are in foster care
Children and youth under the age of 21 who are receiving adoption support
Young adults age 18 to 26 years old who age out of foster care on or after their 18th
birthday
American Indian/Alaska Native (AI/AN) children will not be auto-enrolled, but may opt
into CCW. All other eligible clients will be auto-enrolled.
AHCC complex mental health and substance use disorder
services
AHCC clients who live in Skamania or Clark County receive complex behavioral health
benefits through the Behavioral Health Services Only (BHSO) program in the SW WA
region. These clients will choose between CHPW or MHW for behavioral health
services, or they will be auto-enrolled into one of the two plans. CHPW and MHW will
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
9
use the BHO Access to Care Standards to support determining appropriate level of care,
and whether the services should be provided by the BHSO program or CCW.
AHCC clients who live outside Skamania or Clark County will receive complex mental
health and substance use disorder services from the BHO and managed by DSHS.
Contact Information for Southwest Washington
Beginning on April 1, 2016, there will not be an RSN/BHO in Clark and Skamania counties.
Providers and clients must call the agency-contracted MCO for questions, or call Beacon Health
Options for questions related to an individual who is not eligible for or enrolled in Medicaid.
If a provider does not know which MCO a client is enrolled in, this information can located by
looking up the patient assignment in ProviderOne.
To contact Molina, Community Health Plan of Washington, or Beacon Health Options,
please call:
Molina Healthcare of Washington, Inc. 1-800-869-7165
Community Health Plan of Washington
1-866-418-1009
Beacon Health Options Beacon Health Options
1-855-228-6502
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
10
Resources Available
Topic Resource
Becoming a provider or
submitting a change of address
or ownership
See the agency’s Billers and Providers web page.
Finding out about payments,
denials, claims processing, or
agency managed care
organizations
Electronic or paper billing
Finding agency documents,
(e.g., billing guides, provider
notices, fee schedules)
Private insurance or third-party
liability
How do I check how many
units of therapy the client has
remaining?
Providers may contact the agency’s Medical Assistance
Customer Service Center (MACSC) via:
Telephone toll-free at (800) 562-3022 or
Web form or email
How do I obtain prior
authorization or a limitation
extension?
Requests for prior authorization or limitation extensions must
include:
A completed, typed General Information for
Authorization (HCA 13-835 form). This request form
must be the first page when you submit your request.
A completed Outpatient Rehabilitation Authorization
Request (HCA 13-786 form) and all the documentation
listed on that form and any other medical justification.
Fax your request to: (866) 668-1214
General definitions
See Chapter 182-500 WAC.
Where do I find the agency’s
maximum allowable fees for
services?
See the agency’s Rates Development Fee Schedules.
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
11
Client Eligibility (WAC 182-545-0200 (2))
How can I verify a patient’s eligibility?
Clients may be eligible to receive the outpatient rehabilitation services described in this billing
guide, depending on their benefit package. Providers must verify that a patient has Washington
Apple Health coverage for the date of service, and that the client’s benefit package covers the
applicable service. This helps prevent delivering a service the agency will not pay for.
Verifying eligibility is a two-step process:
Step 1. Verify the patient’s eligibility for Washington Apple Health. For detailed
instructions on verifying a patient’s eligibility for Washington Apple Health, see the
Client Eligibility, Benefit Packages, and Coverage Limits section in the agency’s
current ProviderOne Billing and Resource Guide.
If the patient is eligible for Washington Apple Health, proceed to Step 2. If the patient
is not eligible, see the note box below.
Step 2. Verify service coverage under the Washington Apple Health client’s benefit
package. To determine if the requested service is a covered benefit under the
Washington Apple Health client’s benefit package, see the agency’s Program benefit
packages and scope of services web page.
Note: Patients who wish to apply for Washington Apple Health can do so in one
of the following ways:
1. By visiting the Washington Healthplanfinder’s website at:
www.wahealthplanfinder.org
2. By calling the Customer Support Center toll-free at: 855-WAFINDER
(855-923-4633) or 855-627-9604 (TTY)
3. By mailing the application to:
Washington Healthplanfinder
PO Box 946
Olympia, WA 98507
In-person application assistance is also available. To get information about in-
person application assistance available in their area, people may visit
www.wahealthplanfinder.org or call the Customer Support Center.
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
12
Are clients enrolled in an agency-contracted
managed care organization (MCO) eligible?
(WAC 182-538-060 and -095, or WAC 182-538-063 for Medical Care Services clients)
Yes. Clients enrolled in an agency-contracted managed care plan who are referred for outpatient
rehabilitation services by their primary care provider are eligible to receive those services. When
verifying eligibility using ProviderOne, if the client is enrolled in an agency-contracted managed
care organization (MCO), managed care enrollment will be displayed on the Client Benefit
Inquiry Screen.
All medical services covered under a managed care plan must be obtained by the client through
designated facilities or providers. The managed care plan is responsible for:
Payment of covered services.
Payment of services referred by a provider participating with the plan to an outside
provider.
Are clients enrolled in Primary Care Case
Management (PCCM) eligible? Yes. For the client who has obtained care with a PCCM, this information will be displayed on
the client benefit inquiry screen in ProviderOne. These clients must obtain or be referred for
services provided at ambulatory surgery centers through their PCCM providers. The PCCM
provider is responsible for coordination of care just like the PCP would be in a plan setting.
Note: To prevent claim denials, check the client’s eligibility prior to scheduling
services and at the time of the service, and make sure proper authorization or referral
is obtained from the plan. See the agency’s ProviderOne Billing and Resource Guide
for instructions on how to verify a client’s eligibility.
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
13
Provider Eligibility (WAC 182-545-200)
Who may provide outpatient rehabilitation
services?
The following licensed healthcare professionals may enroll with the agency to provide outpatient
rehabilitation within their scope of practice:
Occupational therapists
Occupational therapy assistants (OTA) supervised by a licensed occupational therapist
Physical therapists or physiatrists
Physical therapist assistants supervised by a licensed physical therapist
Speech-language pathologists who have been granted a certificate of clinical competence
by the American Speech, Hearing and Language Association
Speech-language pathologists who have completed the equivalent educational and work
experience necessary for such a certificate
Note: For other licensed professionals, such as physicians, podiatrists, PA-Cs, ARNPs,
audiologists, and specialty wound centers, refer to the Physician-Related Services/Healthcare
Professional Services Billing Guide and Outpatient Hospital Services Billing Guide.
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
14
Coverage
When does the agency pay for outpatient
rehabilitation? (WAC 182-545-200(4))
The agency pays for outpatient rehabilitation when the services are:
Covered.
Medically necessary, as defined in WAC 182-500-0070.
Within the scope of the eligible client’s medical care program.
Ordered by a physician, physician’s assistant (PA), or an advanced registered nurse
practitioner (ARNP).
Authorized, as required in Chapter 182-545 WAC, Chapter 182-501 WAC, and
Chapter 182-502 WAC, and Authorization.
Begun within 30 days of the date ordered.
Provided by an approved health professional (see Who may provide outpatient
rehabilitation services?).
Billed according to this billing guide.
Provided as part of an outpatient treatment program in:
An office or outpatient hospital setting.
The home, by a home health agency, as described in Chapter 182-551 WAC.
A neurodevelopmental center, as described in WAC 182-545-900.
In any natural setting, if the child is under three and has disabilities. Examples of
natural settings include the home and community setting in which children without
disabilities participate, to the maximum extent appropriate to the needs of the
child.
Note: For information about the new Habilitative Services benefit available
January 1, 2014, see What are habilitative services under this program?
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
15
Duplicate occupational, physical, and speech-therapy services are not allowed for the same client
when both providers are performing the same or similar intervention(s).
What outpatient rehabilitation does the agency
cover for clients age 20 and younger? (WAC 182-545-200(5))
For eligible clients age 20 years and younger, the agency covers unlimited outpatient
rehabilitation, with the exception of clients age 19 through 20 receiving Medical Care Services
(MCS). MCS clients age 19 through 20 have a limited outpatient rehabilitation benefit. See the
outpatient benefit limit tables for occupational therapy, physical therapy, and speech therapy for
MCS clients.
Which clients receive short-term outpatient
rehabilitation coverage? (WAC 182-545-200(6))
The agency covers outpatient rehabilitation for the following clients as a short-term benefit to treat
an acute medical condition, disease, or deficit resulting from a new injury or post-surgery:
Clients age 21 and older
Clients age 19 through 20 receiving MCS
What clinical criteria must be met for the short-
term outpatient rehabilitation benefit?
(WAC 182-545-200 (7))
Outpatient rehabilitation must:
Meet reasonable medical expectation of significant functional improvement within 60
days of initial treatment.
Restore or improve the client to a prior level of function that has been lost due to
medically documented injury or illness.
Meet currently accepted standards of medical practice and be specific and effective
treatment for the client’s existing condition.
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
16
Include an on-going management plan for the client and/or the client’s caregiver to
support timely discharge and continued progress.
What are the short-term outpatient rehabilitation
benefit limits?
The following are the short-term benefit limits for outpatient rehabilitation for adults.
These benefit limits are per client, per calendar year regardless of setting.
Physical therapy: 24 units (equals approximately 6 hours)
Occupational therapy: 24 units (equals approximately 6 hours)
Speech therapy: 6 units (equals a total of 6 untimed visits)
ALWAYS VERIFY AVAILABLE UNITS BEFORE PROVIDING SERVICES
Providers must check with the agency to make sure the client has available units.
Providers may contact the agency’s medical assistance customer services center
(MACSC) toll-free at (800) 562-3022 or by Webform or Email.
For each new prescription for therapy within the same calendar year, whether or
not the original units have been exhausted, providers must first obtain an
authorization for a new evaluation from the agency before providing any further care.
Additional units must be used only for the specific condition they were evaluated or
authorized for. Units do not roll over to different conditions.
For occupational therapy (OT) assessments conducted by the Department of Social and
Health Services (DSHS), see the Coverage Table.
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
17
Occupational therapy
CLIENTS 21 & Older & 19-20 in MCS
benefit limits without prior authorization
Description Limit PA?
Occupational Therapy Evaluation One per client, per calendar year No
Occupational Therapy Re-evaluation
at time of discharge
One per client, per calendar year No
Occupational Therapy 24 Units (approximately 6 hours),
per client, per calendar year
No
CLIENTS 21 & Older & 19-20 in MCS
additional benefit limits with expedited prior authorization
When client’s diagnosis is: Limit EPA#
Acute, open, or chronic non-healing wounds
Up to
24 additional units
(approximately 6 hours),
when medically necessary,
per client,
per calendar year
See Requesting a
Limitation Extension for
requesting units beyond
the additional benefit
limits
-or-
if the client’s diagnosis is
not listed in this table.
870000015
Brain injury with residual functional deficits
within the past 24 months
870000009
Burns – 2nd
or 3rd
degree only 870000015
Cerebral vascular accident with residual
functional deficits within the past 24 months
870000009
Lymphedema 870000008
Major joint surgery – partial or total replacement
only
870000013
New onset muscular-skeletal disorders such as
complex fractures which require surgical
intervention or surgeries involving spine or
extremities (e.g., arm, shoulder, leg, foot, knee,
or hip)
870000014
New onset neuromuscular disorders which are
affecting function (e.g., amyotrophic lateral
sclerosis (ALS), active infection polyneuritis
(Guillain-Barre)
870000016
Reflex sympathetic dystrophy 870000016
Swallowing deficits due to injury or surgery to
face, head, or neck
870000010
Spinal cord injury resulting in paraplegia or
quadriplegia within the past 24 months
870000012
As part of a botulinum toxin injection protocol
when botulinum toxin is prior authorized by the
agency
870000011
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
18
Physical therapy
CLIENTS 21 & Older & 19-20 in MCS
benefit limits without prior authorization
Description Limit PA?
Physical Therapy Evaluation One per client, per calendar year No
Physical Therapy Re-evaluation
at time of discharge
One per client, per calendar year No
Physical Therapy 24 Units (approximately 6 hours),
per client, per calendar year
No
CLIENTS 21 & Older & 19-20 in MCS
additional benefit limits with expedited prior authorization
When client’s diagnosis is: Limit EPA#
Acute, open, or chronic non-healing wounds
Up to
24 additional units
(approximately 6 hours),
when medically necessary,
per client,
per calendar year
See Requesting a
Limitation Extension for
requesting units beyond the
additional benefit limits
-or-
if the client’s diagnosis is
not listed in this table.
870000015
Brain injury with residual functional deficits
within the past 24 months
870000009
Burns – 2nd
or 3rd
degree only 870000015
Cerebral vascular accident with residual
functional deficits within the past 24 months
870000009
Lymphedema 870000008
Major joint surgery – partial or total
replacement only
870000013
New onset muscular-skeletal disorders such as
complex fractures which require surgical
intervention or surgeries involving spine or
extremities (e.g., arm, shoulder, leg, foot, knee,
or hip)
870000014
New onset neuromuscular disorders which are
affecting function (e.g., amyotrophic lateral
sclerosis (ALS), active infection polyneuritis
(Guillain-Barre)
870000016
Reflex sympathetic dystrophy 870000016
Swallowing deficits due to injury or surgery to
face, head, or neck
870000010
Spinal cord injury resulting in paraplegia or
quadriplegia within the past 24 months
870000012
As part of a botulinum toxin injection protocol
when botulinum toxin is prior authorized by the
agency
870000011
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
19
Speech therapy
CLIENTS 21 & Older & 19-20 in MCS
benefit limits without prior authorization
Description Limit PA?
Speech Language Pathology Evaluation One per client, per code,
per calendar year
No
Speech Language Pathology
Re-evaluation at time of discharge
One per client, per evaluation code,
per calendar year
No
Speech Therapy 6 Units (approximately 6 hours),
per client, per calendar year
No
CLIENTS 21 & Older & 19-20 in MCS
additional benefit limits with expedited prior authorization
When client’s diagnosis is: Limit EPA#
Brain injury with residual functional deficits
within the past 24 months
Six additional units,
per client,
per calendar year
See Requesting a
Limitation Extension for
requesting units beyond the
additional benefit limits
-or-
if the client’s diagnosis is
not listed in this table.
870000009
Burns of internal organs such as nasal oral
mucosa or upper airway
870000015
Burns of the face, head, and neck – 2nd
or 3rd
degree only
870000015
Cerebral vascular accident with residual
functional deficits within the past 24 months
870000009
New onset muscular-skeletal disorders such as
complex fractures which require surgical
intervention or surgery involving the vault, base
of the skull, face, cervical column, larynx, or
trachea
870000014
New onset neuromuscular disorders which are
affecting function (e.g., amyotrophic lateral
sclerosis (ALS), active infection polyneuritis
(Guillain-Barre))
870000016
Speech deficit due to injury or surgery to face,
head, or neck
870000017
Speech deficit which requires a speech
generating device
870000007
Swallowing deficit due to injury or surgery to
face, head, or neck;
870000010
As part of a botulinum toxin injection protocol
when botulinum toxin is prior authorized by the
agency
870000011
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
20
Swallowing evaluations
Swallowing (dysphagia) evaluations must be performed by a speech-language pathologist who:
Holds a master's degree in speech-language pathology.
Has received extensive training in the anatomy and physiology of the swallowing
mechanism, with additional training in the evaluation and treatment of dysphagia.
A swallowing evaluation includes:
An oral-peripheral exam to evaluate the anatomy and function of the structures used in
swallowing.
Dietary recommendations for oral food and liquid intake therapeutic or management
techniques.
Swallowing evaluations may include video fluoroscopy for further evaluation of swallowing
status and aspiration risks.
Using timed and untimed procedure codes
For the purposes of this billing guide:
Each 15 minutes of a timed CPT code equals one unit.
Each non-timed CPT code equals one unit, regardless of how long the procedure takes.
If time is included in the CPT code description, the beginning and ending times of each therapy
modality must be documented in the client’s medical record.
What are habilitative services under this
program?
Habilitative services are those medically necessary services provided to help a client partially or
fully attain or maintain developmental age-appropriate skills that were not fully acquired due to a
congenital, genetic, or early-acquired health condition. Such services are required to maximize
the client’s ability to function in his or her environment.
Effective January 1, 2014, and applicable to those clients in the expanded population and
covered by the Alternative Benefit Plan (ABP) only, the agency will cover outpatient physical,
occupational, and speech therapy to treat one of the qualifying conditions listed in the agency’s
Habilitative Services Billing Guide, under Client Eligibility.
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
21
How do I bill for habilitative services?
See the Habilitative Services Billing Guide for details on billing habilitative services. To review
the appropriate ICD diagnosis codes that are required in the primary diagnosis field on the claim
form, see the agency’s Approved Diagnosis Codes by Program web page for Habilitative
Services.
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
22
Coverage Table
Note: Due to its licensing agreement with the American Medical Association, the
agency publishes only the official, short CPT®
code descriptions. To view the full
descriptions, refer to a current CPT book.
The following abbreviations are used in the table below: GP = Physical Therapy; GO =
Occupational Therapy; GN = Speech Therapy; TS = Follow-up service; RT = Right; LT = Left.
An asterisk indicates that a procedure code is included in the benefit limitation for clients age 21
and over and MCS clients age 19 through 20.
Procedure
Code Modifier Short Description PT OT SLP Comments
92521 GN Evaluation of speech
fluency X
1 per client, per code,
per calendar year
92522 GN Evaluate speech
production X
1 per client, per code,
per calendar year
92523 GN Speech sound lang
comprehen X
1 per client, per code,
per calendar year
92524 GN Behavral qualit analys
voice X
1 per client, per code,
per calendar year
92507* GN Speech/hearing therapy X
92508* GN Speech/ hearing therapy X
92526* GO, GN Oral function therapy X X
92551* GN Pure tone hearing test
air X
92597* GN Oral speech device eval X
92605
GN
Eval for rx of
nonspeech device 1 hr X
Limit 1 hour
Included in the
primary services
Bundled
92618 GN Eval for rx of
nonspeech device addl X
Add on to 92605
each additional 30
minutes
Bundled
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
23
Procedure
Code Modifier Short Description PT OT SLP Comments
92606 GN Nonspeech device
service X
Included in the
primary services
Bundled
92607 GN Ex for speech device rx
1 hr X Limit 1 hour
92608 GN Ex for speech device rx
addl X
Each additional 30
min
Add on to 92607
92609* GN Use of speech device
service X
92610 GN Evaluate swallowing
function X
No limit
92611 GN Motion
fluoroscopy/swallow X No longer limited
92630* GN Aud rehab pre-ling
hear loss X
92633* GN Aud rehab post-ling
hear loss X
95831* GP, GO Limb muscle testing
manual X X
1 muscle testing
procedure, per client,
per day. Muscle
testing procedures
cannot be billed in
combination with
each other. Can be
billed alone or with
other PT/OT
procedure codes.
95832* GP, GO Hand muscle testing
manual X X
1 muscle testing
procedure, per client,
per day. Muscle
testing procedures
cannot be billed in
combination with
each other. Can be
billed alone or with
other PT/OT
procedure codes.
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
24
Procedure
Code Modifier Short Description PT OT SLP Comments
95833* GP, GO Body muscle testing
manual X X
1 muscle testing
procedure, per client,
per day. Muscle
testing procedures
cannot be billed in
combination with
each other. Can be
billed alone or with
other PT/OT
procedure codes.
95834* GP, GO Body muscle testing
manual X X
1 muscle testing
procedure, per client,
per day. Muscle
testing procedures
cannot be billed in
combination with
each other. Can be
billed alone or with
other PT/OT
procedure codes.
95851* GP, GO Range of motion
measurements X X Excluding hands
95852* GP, GO Range of motion
measurements X X
Including hands
96125* GP, GO,
GN
Cognitive test by hc
pro X X X
1 per client,
per calendar year
97001 GP PT evaluation X 1 per client,
per calendar year
97002 GP PT re-evaluation X 1 per client,
per calendar year
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
25
Procedure
Code Modifier Short Description PT OT SLP Comments
97003
GO Occupational Therapy
Evaluation X
1 per client, per
calendar year
GO
DSHS Occupational
Therapy Evaluation
Personal Care for
Children
X
EPA required.
One per client, unless
change of residence
or condition
OT Eval for bedrails
and personal care are
a DSHS program.
Use EPA#
870001326 with
billing code 0434-
97003, assess for
bedrails and bedrail
safety.
GO
DSHS Occupational
Therapy Evaluation
(bed rail assessment)
X
EPA required.
One per client, unless
change of residence
or condition
OT Eval for bedrails
and personal care are
a DSHS program.
Use EPA#
870001326 with
billing code 0434-
97003, assess for
bedrails and bedrail
safety.
97004
GO
Occupational Therapy
Re-Evaluation X
1 per client, per
calendar year
97005
Athletic train eval Not covered
97006
Athletic train re-eval
Not covered
97010 GP, GO Hot or cold packs
therapy X X Bundled
97012* GP Mechanical traction
therapy X
97014* GP GO, Electric stimulation
therapy X X
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
26
Procedure
Code Modifier Short Description PT OT SLP Comments
97016* GP Vasopneumatic device
therapy X
97018* OP, GO Paraffin bath therapy X X
97022* GP Whirlpool therapy X
97024* GP Diathermy eg
microwave X
97026* GP Infrared therapy X
97028* GP Ultraviolet therapy X
97032* GP, GO Electrical stimulation X X Timed 15 min units
97033* GP Electric current therapy X Timed 15 min units
97034* GP, GO Contrast bath therapy X X Timed 15 min units
97035* GP Ultrasound therapy X Timed 15 min units
97036* GP Hydrotherapy X Timed 15 min units
97039* GP Physical therapy
treatment X
97110* GP, GO Therapeutic exercises X X Timed 15 min units
97112* GP, GO Neuromuscular re-
education X X Timed 15 min units
97113* GP, GO Aquatic
therapy/exercises X X Timed 15 min units
97116* GP Gait training therapy X Timed 15 min units
97124* GP, GO Massage therapy X X Timed 15 min units
97139* GP Physical medicine
procedure X
97140* GP, GO Manual therapy X X Timed 15 min units
97150* GP, GO Group therapeutic
procedures X X
97530* GP, GO Therapeutic activities X X
Timed 15 min units
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
27
Procedure
Code Modifier Short Description PT OT SLP Comments
97532* GO, GN Cognitive skills
development X X Timed 15 min units
97533* GO, GN Sensory integration
X X Timed 15 min units
97535* GP, GO Self care mngment
training X X Timed 15 min units
97537* GP, GO Community/work
reintegration X X Timed 15 min units
97542 GP, GO Wheelchair mngment
training X X
1 per client, per
calendar year
Assessment is limited
to four 15-min units
per assessment.
Indicate on claim
wheelchair
assessment
97545
Work hardening
Not covered
97546
Work hardening add-
on Not covered
97597* GP, GO
Rmvl devital tis 20
cm/<
X X
Do not use in
combination with
11042-11047. Limit
one per client, per
day
97598* GP, GO Rmvl devital tis addl
20 cm< X X
1 per client, per day
Do not use in
combination with
11042-11047.
97602* GP, GO Wound(s) care non-
selective X X
1 per client, per day
Do not use in
combination with
11042-11047.
97605 GP, GO Neg press wound tx <
50 cm X X Bundled
97606 GP, GO Neg press wound tx >
50 cm X X Bundled
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
28
Procedure
Code Modifier Short Description PT OT SLP Comments
97750* GP, GO Physical performance
test X X
Do not use to bill for
an evaluation
(97001) or
re-eval (97002)
97755 GP, GO Assistive technology
assess X X Timed 15 min units
97760* GP, GO Orthotic mgmt and
training X X
Two 15-minute units,
per client, per day.
Can be billed alone
or with other PT/OT
procedure codes.
97761* GP, GO Prosthetic training X X Timed 15 min units
97762
GP, GO
-or-
GP,GO &
TS
C/o for orthotic/prosth
use
X X
Use this code for
DME assessment.
1 per client, per
calendar year
Use with two 15-min
units per session.
Use modifier TS for
follow up service.
Can be billed alone
or with other PT/OT
procedure codes.
97799*
GP, GO
&
RT or LT
Physical medicine
procedure X X
Use this code for
custom hand splints.
1 per hand, per
calendar year
Use modifier to
indicate right or left
hand. Documentation
must be attached to
claim.
S9152 GN Speech therapy re-eval
X
1 per client, per
evaluation code,
per calendar year
Outpatient Rehabilitation
CPT® codes and descriptions only are copyright 2014 American Medical Association.
29
The agency does not pay:
Separately for outpatient rehabilitation that is included as part of the reimbursement for
other treatment programs. This includes, but is not limited to, hospital inpatient and
nursing facility services.
A healthcare professional for outpatient rehabilitation performed in an outpatient hospital
setting when the healthcare professional is not employed by the hospital. The hospital
must bill the agency for the services.
Where can I find the fee schedule?
Rehabilitation services provided in an office setting are paid according to the agency’s
Outpatient Rehabilitation Fee Schedule.
Rehabilitation services provided in hospital and hospital-based clinic settings are subject
to the agency’s Outpatient Prospective Payment System (OPPS) Fee Schedule and
Outpatient Hospitals Fee Schedule.
Outpatient Rehabilitation
30
Authorization
What are the general guidelines for
authorization?
When a service requires authorization, the provider must properly request written
authorization in accordance with the agency’s rules, this billing guide, and applicable
provider notices.
When the provider does not properly request authorization, the agency returns the request
to the provider for proper completion and resubmission. The agency does not consider the
returned request to be a denial of service.
Upon request, a provider must provide documentation to the agency showing how the
client’s condition met the criteria for using the expedited prior authorization (EPA) code
and/or limitation extension.
The agency’s authorization of service(s) does not guarantee payment.
The agency may recoup any payment made to a provider if the agency later determines
that the service was not properly authorized or did not meet the EPA criteria. See WAC
182-502-0100(1)(c) and WAC 182-544-0560(7).
EPA – What are the additional units for clients
age 21 and older, and clients age 19 through 20 in
MCS?
When a client meets the criteria for additional benefit units of outpatient rehabilitation, providers
must use the EPA process. The EPA units may be used once per client, per calendar year for
each therapy type. When a client’s situation does not meet the conditions for EPA, a provider
must request a limitation extension (LE).
Expedited Prior Authorization
Enter the appropriate 9-digit EPA code on the billing form in the authorization number
field, or in the Authorization or Comments field when billing electronically. EPA
codes are designed to eliminate the need for written authorization.
Outpatient Rehabilitation
31
EPA numbers and LEs do not override the client’s eligibility or program limitations. Not
all eligibility groups receive all services.
How can I request an LE?
When clients reach their benefit limit of outpatient rehabilitation has been reached (the initial
units and any additional EPA units, if appropriate), a provider may request authorization for an
LE from the agency.
The agency evaluates requests for authorization of covered outpatient rehabilitation that exceed
limitations in this billing guide on a case-by-case basis in accordance with
WAC 182-501-0169. The provider must justify that the request is medically necessary (as
defined in WAC 182-500-0070) for that client.
Note: Requests for an LE must be appropriate to the client’s eligibility and/or
program limitations. Not all eligibility programs cover all services.
The following documentation is required for all requests for LE:
A completed General Information for Authorization form, HCA 13-835
(this request form MUST be the first page when you submit your request)
A completed Outpatient Rehabilitation Authorization Request form, HCA 13-786, and all
the documentation listed on this form and any other medical justification
Fax LE requests to: (866) 668-1214
Outpatient Rehabilitation
32
Billing and Claim Forms
Effective for claims billed on and after October 1, 2016 All claims must be submitted electronically to the agency, except under limited circumstances.
For more information about this policy change, see Paperless Billing at HCA.
This billing guide still contains information about billing paper claims.
This information will be updated effective January 1, 2017.
Are referring provider NPIs required on all
claims? Yes. Providers must use the referring provider’s national provider identifier (NPI) on all claims in
order to be paid. If the referring provider’s NPI is not listed on the claim form, the claim may be
denied. Providers must follow the billing requirements listed in the agency’s ProviderOne Billing
and Resource Guide.
How is the CMS-1500 claim form completed?
Instructions on how to bill professional claims and crossover claims electronically can be found
on the agency’s Billers and Providers web page, under Webinars. See Medical provider
workshop. Also, see Appendix I of the agency’s ProviderOne Billing and Resource Guide for
general instructions on completing the CMS-1500 claim form.
Are modifiers required for billing? Yes. Providers must use the appropriate modifier when billing the agency:
MODALITY MODIFIERS
Physical Therapy GP
Occupational Therapy GO
Speech Therapy GN
Audiology and Specialty Physician AF
Outpatient Rehabilitation
33
What are the general billing requirements?
Providers must follow the agency’s ProviderOne Billing and Resource Guide. These billing
requirements include, but are not limited to:
Time limits for submitting and resubmitting claims and adjustments
What fee to bill the agency for eligible clients
When providers may bill a client
How to bill for services provided to primary care case management (PCCM) clients
Billing for clients eligible for both Medicare and Medicaid
Third-party liability
Record keeping requirements
The outpatient rehabilitation benefit limits for clients age 21 and older and clients age 19 through
20 in MCS apply to the skilled therapy services provided through a Medicare-certified home
health agency, as well as therapy provided by physical, occupational, and speech therapists in
outpatient hospital clinics and free-standing therapy clinics.
Use billing and servicing taxonomy specific to the service being billed. Do not mix modalities on
the same claim form. For example, use the billing and servicing taxonomy specific to physical
therapy for billing physical therapy services. Do not bill occupational therapy services on the
same claim form as physical therapy services.
Bill timely. Claims will pay in date of service order. If a claim comes in for a previous date of
service, the system will automatically pay the earlier date and recoup or adjust the later date.
Home health agencies
Home health agencies must use the following procedure codes and modifiers when billing the
agency:
Modality Home Health
Revenue Codes
New Home Health
Procedure Codes Modifiers
Physical Therapy 0421 G0151 = 15 min units GP
Occupational Therapy 0431 G0152 = 15 min units GO
Speech Therapy 0441 92507 = 1 unit GN
Outpatient Rehabilitation
34
Outpatient hospital or hospital-based clinic
setting
Hospitals must use the appropriate revenue code, CPT code, and modifier when billing the
agency:
Modality Revenue Code Modifiers
Physical Therapy 042X GP
Occupational Therapy 043X GO
Speech Therapy 044X GN
See the agency’s Outpatient Hospital Billing Guide for further details.